Insurance/Payment Information

Insurance/Payment Information

This page will collect your insurance/payment information so we can tell you what your insurance benefits are. You will be able to select a date and time to see our Intake Coordinator after this page. If you cannot find a date or time that fits, please contact us during office hours (M-F, 9-6) to find a time.617-286-6513.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Insurance Company or Enter Self Pay ($150 first session; $135 thereafter)*
Insurance Subscriber ID or Enter Self Pay*
Insurance Phone Number (see back of card) or Enter Self Pay*
Pressing submit will take you to a third party site, called BREEZE, where you will be able to request an appointment time with our Intake Coordinator.
Should be Empty: